This case study is aimed at providing a descriptive assessment of the key features of Vietnams Social Health Insurance (SHI), focusing on the impediments to integrating the poor into universal coverage.
... See More + The trajectory of SHI in Vietnam is similar to that of many other countries in the East Asia and Pacific region. The poor were covered under a separate Health Care Fund for the Poor to begin with. The 2009 Law on Health Insurance merged all of the different programs into one. Health insurance premiums for the poor were fully subsidized by the government and enrolment became mandatory, resulting in almost complete enrollment of the poor by 2011. Vietnam has combined elements of contributory social health insurance with substantial levels of tax financing to provide coverage for the poor and informal sector. The case study is structured as follows. Section 2 describes the institutional structure and system characteristics of Vietnams SHI. Section 3 addresses the main topic of the case study - the impediments to integrating the poor. Section 4 concludes by addressing the pending agenda.
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This case study summarizes the responses to the questionnaire on The Nuts and Bolts of the Program Expanding Health Coverage to the Poor, developed within the framework of the World Banks UNICO - Universal Challenge Program.
... See More + By so doing, it assesses the key features and the achievements and challenges of Brazils Primary Care Strategy (PCS) and analyzes the contribution of this strategy to the establishment and implementation of universal coverage. Section 2 provides context for the discussion by summarizing key reforms and the impact of the PCS and describes Brazils health care delivery and financing system. The institutional architecture and interaction of the health care program (HCP), in this case the PCS, is discussed in section 3. Sections 4 through 8 outline the main features of the strategy, including the identification and targeting of beneficiaries, management of public funds, services covered, and the information environment. The case study concludes with a discussion of lessons learned (section 9) and the pending agenda (section 10).
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This paper describes the functioning and performance of Argentinas Provincial Maternal and Child Health Investment Program, commonly referred to as Plan Nacer.
... See More + The program is aimed at increasing access - for uninsured pregnant women and children under six years old - to a basic set of health services known to effectively address the main causes of maternal and child mortality, while improving the effectiveness and efficiency of the health system. The program supports the development and implementation of publicly funded provincial maternal and child health insurance and the introduction of highly innovative results-based financing mechanisms at the national, provincial, and provider levels. This document is organized as follows. Section 2 provides an overview of the Argentine health care system, including a description of public health, primary care, and supply-side efforts, to put in context the implementation of Plan Nacer. Section 3 presents a detailed description of the main features of the program, including the institutional architecture; the targeting, identification, and enrolment of beneficiaries; the management of the programs funds and benefits package; and the information environment of Plan Nacer. Section 4 provides a discussion of the highly innovative results-based financing mechanisms included in the design of the program. Section 5 draws some conclusions on the pending agenda and challenges ahead.
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Indias health sector continues to be challenged by overall low levels of public financing, entrenched accountability issues in the public delivery system, and the persistent dominance of out-of-pocket spending.
... See More + In this context, this case study describes three recent initiatives introduced by the central and state governments in India, aimed at addressing some of these challenges and improving the availability of and access to health services, particularly for the poor and vulnerable groups in the country. This includes two federal schemes introduced by the Government of India-the National Rural Health Mission (NRHM) of the Ministry of Health and Family Welfare and the Rashtriya Swasthya Bima Yojana (RSBY) of the Ministry of Labor and Employment-and the Rajiv Aarogyasri scheme launched by the state government of Andhra Pradesh. The three schemes discussed in this case study were designed and implemented by different agencies almost in parallel, over the same time period, and used different financing and delivery approaches. A discussion of the mechanics and operational features of these programs has been undertaken to unravel the underlying complexities, interactions, and interdependencies of these programs within the countrys health system. The remainder of this case study on Indias march toward universal health coverage focuses on three recent, prominent programs, and includes a discussion on the institutional structure of these programs and their interactions within the countrys health system, their mechanisms for beneficiary targeting and enrolment, the benefits packages covered by them, accompanying innovations in public financial management, and their information environment. Annex one presents an overview of the health system and health financing in India, and annex two discusses the evolutionary context of Indias Government sponsored health insurance schemes. The discussion of the mechanics and operational features of these programs has been undertaken to unravel the underlying complexities, interactions, and interdependencies within these programs. The case study also aims to contribute to the ongoing debate within the Indian health sector, with opinions divided between investments in traditional input-based health spending for publicly managed health facilities versus demand-side financing, purchasing of care, and involving private providers and intermediaries in delivering services financed by public money. The case study also aims to share how the lessons learned by one program can be applicable more widely within the Indian health system and beyond.
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Jamaicas primary health care system was a model for the Caribbean region in the 1990s. Because of it, Jamaicans enjoy relatively better health status than people in other countries of similar income level in the Caribbean region.
... See More + However, Jamaicas health system is being severely challenged by persistent and reemerging infectious diseases and by the rapid increase in noncommunicable diseases (NCDs) and injuries. At the same time, the country has suffered from low economic growth and carries a high debt burden, which leaves limited fiscal space for improving health care. The Government of Jamaica has been trying to sustain the gain in health outcomes and improve access to health care for its population in an environment of constrained resources during the last decade. With the establishment of the Jamaica National Health Fund (NHF) in 2003 and the abolition of user fees at public facilities in 2008, the Government of Jamaica has taken steps toward achieving universal coverage. This study reviews the achievements and challenges in expanding universal access in Jamaica and assesses the impact of the NHFs drug-subsidy programs and the abolition of user fees on universal access, and discusses policy options for achieving universal coverage.
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In this case study the paper describes the evolution of the Kyrgyz health care system and discusses challenges in ensuring universal access to basic health care services.
... See More + Section one provides an overview of the Kyrgyz health system and of the national health care reform programs that started in 2001 with Manas (2001-2005) and which have been continued with Manas Taalimi (2006-2011), and the recently adopted Den Sooluk (2012-2016). Section two provides a detailed discussion of the SGBP that follows a universal approach as it applies to all citizens, and describes the management of public funds and the information environment of the State Guaranteed Benefit Package (SGBP). Section three draws lessons from Kyrgyz national health reforms for universal health coverage for other countries with very limited public resources, widespread poverty, and high levels of corruption. Section four discusses the remaining challenges for universal health coverage for the poor and how the provision of good-quality care forms an important part of the agenda for the recently adopted Den Sooluk program.
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The commonwealth of Massachusetts, one of the 50 states in the United States of America, has achieved near universal health coverage of its 6.6 million residents after a landmark reform made health insurance mandatory for all residents in 2006.
... See More + The reform was only the latest step in a sequence of national and state programs that successively enrolled more people in private and public health insurance programs over a period of four decades. Massachusetts passed chapter 58 of the acts of 2006, the Massachusetts health care reform law, on April 12, 2006, and over a five-year period, more than 400,000 previously uninsured residents were provided with comprehensive health benefits. As of 2012, 98.2 percent of the population is covered, including 99.8 percent of children. Massachusetts has the highest rate of health insurance coverage of any state in the country. The program has widespread popular support, and it served as a model for the design of President Obamas affordable care act, which established a plan for mandatory coverage on a national basis for the first time in the United States. This report will briefly describe the reform and its context, but will focus for purposes of simplicity on the operational details of the mass health program of health insurance for the poor. A discussion of the administration and management of Mass Health can offer a glimpse into the inner workings of all other insurance plans in the commonwealth. Mass health, private insurance, and Commonwealth Care share similar tools, controls, and strategies.
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This paper focuses on recent and significant health reform implemented in 2005, known as Universal Access with explicit guarantees (Acceso Universal con Garantias Explicitas - AUGE or GES), which mandated SHI insurers to adopt a broad benefits package defined via explicit legal guarantees for all beneficiaries.
... See More + This innovative reform is a policy reaction to that which previously existed in Chile and which is widespread in many developing countries, whereby the health rights of citizens remain largely undefined or implicit. Limited public resources imply in those countries that access to health care is rationed through queues, patient deflection, legal or under-the-table user fees, and low-quality care. This paper describes the AUGE reform, its implementation, and the functioning of AUGE for the poor and for non-poor citizens. This paper is organized as: section two provides a brief historic overview of health coverage in Chiles SHI system. Section three describes the SHI system in existence today. Section four describes the services offered and mechanisms in place to cover the poor under SHI, while section five spells out the benefits of SHI. Section six introduces the AUGE health reform of 2005, which sought to broaden and make explicit the rights of all SHI beneficiaries. Section seven offers information about the flows and magnitudes of health financing in SHI. Section eight focuses on the system used by Fonasa to target the poor. Section nine explains how Fonasa manages AUGE. Section ten comments on the information environment of AUGE. Section eleven addresses the equity and fiscal implications of expanding the AUGE benefits. Finally, section twelve proposes a pending policy agenda related to the coverage of the poor under SHI and the definition and management of benefits.
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The march to Universal Health Coverage (UHC) in China is unparalleled. Since the establishment of the State Council Medical Reform team in 2006,4 the basic objective of Chinas health reforms has been to provide the whole nation with basic medical and health care, while ensuring equal access to, and affordability of, health services.
... See More + The Chinese government announced the national three-year reform plan in 2009, after which the country has made remarkable progress toward achieving nearly universal health coverage. The recent health reform initiatives under the 12th Five-Year Plan (2011-2015) continue to center on five areas. Building on recent experience, more effort is directed toward a structural change of the health system and building an environment that will facilitate policy implementation. This includes optimizing resource distribution, encouraging hospital competition, strengthening regulation and accountability, and enhancing human resources and information technology. While China has successfully extended the breadth of Health Coverage to the Poor (HCP), its scope (the comprehensiveness of services covered) and depth (the degree of financial risk protection) appear to be insufficient. Hospital admissions have increased significantly; suggesting improved access, up to 50 percent of current admissions may be amenable to more cost-effective outpatient care. Thus, it is critical to look into problems beyond the HCP program design, such as institutional arrangements, intergovernmental transfers, and supply constraints. This case study concludes with a discussion of the impacts of HCP and the needed next steps to advance HCP as an intermediate objective to the countrys longer-term goals of equitable access and high quality of services.
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This case study provides an overview of the contribution of Colombias compulsory health insurance, particularly its Subsidized Regime (SR), to universal health care coverage in the country, and the current challenges the SR faces.
... See More + The case study is based on discussions with stakeholders from academia and the public and private sectors. The report is divided into four sections: (1) country context and health outcomes; (2) the SR within the institutional architecture of the national health insurance system; (3) the subsidized regime: considerations on equity in the context of the public debate on the right to health care in Colombia; and (4) policy decisions and key areas of the agenda for the short and medium term.
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The objective of this paper is to assess the key interventions Costa Rica has developed to expand health coverage for the poor and other vulnerable groups, with an emphasis on its approach to primary health care.
... See More + Universal health coverage in Costa Rica is provided through a single national health insurance program. This program, which protects the poor without the pitfalls of a fragmented system, and the sustained policies that have enabled the building of a solid primary health care system, is broadly recognized as a success story. At the same, time new challenges are emerging to sustaining the success of Costa Ricas universal health coverage. Social Security of Costa Rica (Caja Costarricense de Seguridad Social, CCSS) faces increased production costs and demographic and epidemiological changes in a rapidly aging population. This report is divided into three broad sections: (1) objective of the case study and health system overview; (2) primary health care and the organization of health services within CCSS; and (3) agenda of key policy decisions for a renewed primary health care approach as part of a more responsive and sustainable health insurance system.
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Ethiopia has made substantial progress in improving health outcomes during the last decade and is on track to achieve some of the health Millennium Development Goals.
... See More + Innovative strategies to improve household behaviors and coverage of basic health care services contributed to Ethiopias achievements, and the Health Extension Program (HEP) remains the core of such innovations and provides a model for countries struggling to improve health outcomes in a resource-constrained setting. The program rests on an accelerated expansion of basic health infrastructure and local human resources with required skills to scale-up delivery of high-impact interventions focusing on improving the supply of and enhancing demand for a well-defined package of essential promotive, preventive, and curative health services. The objectives of the case study are to provide a detailed description of (a) the context for the introduction of the program; (b) the scope of the service package delivered under the program; and (c) the institutional arrangements and the links with the rest of the health system. The case study also summarizes and discusses the evidence of the programs achievements and the challenges to achieving universal primary health care coverage. The study also discusses the importance of political will and commitment in introducing such large-scale innovations in improving service delivery and mobilizing the community in a resource-constrained setting.
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Since the 2011 popular revolution in Tunisia, calls for a new social contract have been made to improve social inclusion, including addressing gaps in health care coverage for the vulnerable households.
... See More + This paper evaluates Tunisias Free Medical Assistance for the Poor (FMAP) and seeks to identify opportunities to improve universal coverage in Tunisia. The study focuses on the structural and institutional framework of health care coverage for the poor in Tunisia in terms of strengths, weaknesses, and recommendations for achieving universal coverage. The paper reviews Tunisias health financing and delivery system with a special emphasis on FMAP, and analyzes the main structural and targeting challenges the program faces. The distinctive characteristic of this paper is the focus on institutional design and organizational practice of FMAP. The legal and regulatory framework is assessed in terms of management, beneficiary targeting methods, benefits package, and the information environment. Section 2 provides an overview of health financing and service delivery in Tunisia, including the relationship between the FMAP and the main financing schemes. Section 3 describes key supply-side issues in terms of primary health care provision for the poor. Section 4 assesses the institutional framework of the FMAP in greater detail and its linkages to the health care delivery system. Section 5 focuses on beneficiary selection and targeting methods under the FMAP. Section 6 examines public financial management under the FMAP, which is followed by a discussion in Section 7 of the benefits package. Sections 8 and 9 describe the information environment of the FMAP and how this links to the special focus of future financing reforms. The concluding section discusses the pending agenda and priorities for the FMAP moving forward.
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Georgia launched its Medical Insurance Program (MIP) for the poor in 2006. This program draws from general tax revenues to provide comprehensive, means-tested health insurance to the poorest 20 percent of the population as identified by a proxy means test.
... See More + The government contracts private insurance companies who serve as financial risk carriers and purchasing agents for the program. MIP is well targeted to the poor and has had a major impact on improving financial protection of its beneficiaries. It has also served as a launching pad for significant investments in hospitals and information technology (IT) systems. In brief, MIP is a program funded through general taxation that provides a fairly comprehensive benefits package of health services to the poorest 20 percent of the population as identified via a proxy means test. There are no copayments for services. Although run by a state purchaser during the first two years, since 2008 its key feature has been that private insurance companies are contracted by the Ministry of Health to bear financial risk and to purchase services from both public and private providers on behalf of poor beneficiaries. The government sets policy, pays a per capita premium per beneficiary to private insurers, and conducts program oversight. This case study provides an overview of how MIP is designed, its achievements to date, and challenges for the future. A key theme discussed in further detail, and of potential interest to other countries contemplating a push toward the achievement of universal health coverage, is the contracting of private insurance companies to purchase services on behalf of the poor. Some attention is also given to MIPs targeting approach.
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Thailands model of health financing and its ability to rapidly expand health insurance coverage to its entire population presents an interesting case study.
... See More + Even though it is still a middle-income country with limited fiscal resources, the country managed to reach universal health insurance coverage through three main public schemes: the Universal Coverage Scheme (UCS), the Social Security Scheme (SSS), and the Civil Servant Medical Benefit Scheme (CSMBS). The UCS, which is the largest and most instrumental scheme in the expansion of coverage to the poor and to those in the informal sector, is the focus of this report. It describes the nuts and bolts of the UCS as a key component of the health financing system in Thailand. It analyzes Thailands experience in health insurance coverage expansion within limited fiscal constraints through various mechanisms to contain costs. It also explores the two commonly discussed approaches for the universal coverage movement: the expansion model (starting from covering the poor and formal sector to universal coverage) and the comprehensive approach (covering the entire population at the same time).
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This is a nuts and bolts case study of the implementation of the government-financed health coverage program (HCP) for poor households in the Philippines.
... See More + The data and information in this case study largely draws upon the 2011 World Bank Report Transforming the Philippine health sector: challenges and Future Directions (Chakraborty et al. 2011), and technical work undertaken for World Bank support to the Government of the Philippines (GOP) for universal health coverage (UHC) in the Philippines.2 The aim of the case study is to understand how the HCP was implemented, what worked and did not work, and how it impacted expected results under the HCP. In 1996, similarly to many low- and middle-income countries, the Philippines introduced a demand-side program for poor households (the Sponsored Program). The objective was to improve access of poor households to needed health services without experiencing a financial burden. Unlike many countries, where such programs are stand alone, in the case of the Philippines it was integrated into the National Health Insurance Program (NHIP). This is a sound design feature from the perspective of providing optimal risk pooling and redistribution, and the Philippines is a model for other countries implementing similar schemes for poor households. The national government has included financing for poor households in the medium-term national expenditure program, so there is no danger of uncertainty in financing. PhilHealth is incrementally strengthening its contract implementation and monitoring mechanisms. The main challenge now facing the HCP is whether these revamped efforts will be able to quickly address the problem of lack of access to quality and affordable services for poor households. There are supply side constraints, facilities will need to be upgraded to obtain Philhealth accreditation. Accredited health facilities will have to be held accountable for delivering services and where public services are not available, mechanisms for incentivizing the private sector for outreach to poor households will have to be deployed. Much depends on Phil Healths capacity as an effective purchaser of health services. Local government unit (LGU) facility capacity to respond to revamped PhilHealth incentives is another bottleneck. The other challenge is whether the Department of Health and PhilHealth will be able to quickly build the monitoring and evaluation systems needed to track HCP implementation and make the necessary in-flight adjustments in implementation in a timely manner.
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This case study unravels Turkeys path to universal coverage. It outlines both the transformation of the health system and the performance of the Yesil Kart, the Green Card, program, a noncontributory health insurance scheme for the poor.
... See More + Initially launched in 1992, the Green Card program has seen a rapid expansion in the number of beneficiaries and program benefits since the implementation of the Health Transformation Program, or HTP in 2003, with the number of beneficiaries more than tripling, from 2.5 million beneficiaries in 2003 to 9.1 million beneficiaries in 2011. In addition, both the coverage and targeting of the program improved substantially. While the Green Card program initially began as a separate targeted scheme for the poor, in January 2012 it became part of the UHI scheme managed by Social Security Institution, or SSI. As this study will show, gradual steps were taken over the years to expand coverage, improve targeting, and expand benefits of the Green Card program to align it with the UHI. This, combined with the improvements in service delivery within a comprehensive reform of the health sector, makes Turkey a unique example of universal coverage for quality health services. The study is organized as follows. Section two briefly outlines Turkeys health reform and how health care is currently organized and delivered. Section three describes the Green Card Program, it evolution, and its performance. The final section discusses the pending agenda.
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Since the signing of the 1996 Peace Accords, Guatemala has made efforts to establish economic and political stability, and to improve its social indicators.
... See More + The countrys Constitution states that access to health care is a basic right of all Guatemalans. In practice, however, it has been challenging for the Government of Guatemala to guarantee this right using public facilities. As a result, it has been trying to improve access to health services using both Ministry of Public Health and Social Assistance (MOH) facilities and staff, and alternative health service providers, particularly nongovernmental organizations (NGOs). This case study reviews the experience implementing the Expansion of Coverage Program (Programa de Extension de Cobertura, PEC) that was established by the Government of Guatemala in 1997 to improve coverage of health and nutrition services to poor, rural, and largely indigenous areas by contracting NGOs. It describes its origins; its package of services; contracting, financing, monitoring, and supervision mechanisms; and its contributions to improving access and strengthening primary health care services in Guatemala. It also discusses opportunities and challenges that need to be addressed to continue to improve health services coverage in the country.
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This case study describes the Government of Kenyas initiative to expand the supply of health care and strengthen primary health care through implementation of the Health Sector Services Fund (HSSF), which provides direct cash transfers to primary health facilities.
... See More + This initiative, launched in 2010, is a direct response to challenges identified by the Public Expenditure Tracking Surveys in making funds for operation and maintenance available to the health facilities, and builds on lessons from initiatives supported by the Danish International Development Agency (DANIDA) in the Coastal Region.
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With a population of 113 million and a per-capita Gross Domestic Product, or GDP of US$10,064 (current U.S. dollars), Mexico is one of the largest and highest-income countries in Latin America and the Caribbean (LAC).
... See More + The country has benefited from sustained economic growth during the last decade, which was temporarily interrupted by the financial and economic crisis. Real GDP is projected to grow 3.8 percent and 3.6 percent in 2012 and 2013, respectively (International Monetary Fund, or IMF 2012). Despite this growth, poverty in the country remains high; with half of the population living below the national poverty line. The country is also highly heterogeneous, with large socioeconomic differences across states and across urban and rural areas. In 2010, while the extreme poverty ratio in the Federal District and the states of Colima and Nuevo Leon was below 3 percent, in Chiapas, Guerrero, and Oaxaca it was 25 percent or higher. These large regional differences are also found in other indicators of well-being, such as years of schooling, housing conditions, and access to social services. This case study assesses key features and achievements of the Social Protection System in Health (Sistema de Proteccion Social en Salud) in Mexico, and particularly of its main pillar, Popular Health Insurance (Seguro Popular, PHI). It analyzes the contribution of this policy to the establishment and implementation of universal health coverage in Mexico. In 2003, with the reform of the General Health Law, the PHI was institutionalized as a subsidized health insurance scheme open to the population not covered by the social security schemes. Today, the PHI covers all of its intended affiliates, about 52 million people.
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